post graduate from dmch ludhiana

1. PRESENTED BY:- DR.INDERPREET
SINGH
PG RESIDENT
GEN. SURGERY DMCH
Neck Dissections

2. 1. Surgicalanatomynecessaryforneckdissection
2. Variouslevelsof lymphnodesandwhyarethey
important
3. Incisionsforneckdissection

3. 1. Introduction
2. Historical perspective
3. Anatomicalconsiderations
4. Classificationof neckdissection
5. Incisions
6. Conclusion
7. References

4.  World Oral health Report 2003 suggests that Oral
cancers are a major problem in the regions of the
worldwheretobaccohabitsin theformof chewing
and / or smoking withor withoutalcohol intakeare
common.
 Usually 91% of the cases occur after the age of
forty years and highest incidence between ages
60and70 years.

5. 

One-thirdofallcasesofOSCC presentasstage
I/II disease&two-thirdsofpatientspresentwith
stageIIIorIVdisease.
TreatmentofOSCC isprimarilysurgicalfollowed
by chemoradiotherapy.
 Currenttrendsarechangingandtheabove
modalitiesmightbeusedinaninterchangeable
sequence.i.e. surgeryfollowedbychemoradiation
orchemoradiotherapyfollowedbysurgical
salvageorneckdissection.

6.  Patientswithcervicalnodalmetastasesshow
increasedlikelihoodfordistantmetastasesand
local recurrence.
 Exceptdistantmetastases,themostadverse
independentprognosticfactorinOSCC is
presenceof positivecervicallymphnodesand
prognosisinsuchpatientswithextranodalspread
of tumorispoor.

7.  The term "neck dissection" refers to a
surgical procedure in which the fibro-fatty
soft tissue content of the neck is excised
to remove the lymph nodes

8.  Byknowingtheanatomy.
 By knowing the patterns of the cervical
lymph node drainage.
 Therationalebehindneckdissections.
 Workupandstagingof necknodemetastases.
 Thetypesof neckdissections.

9. In 1906
pape
r of
th
e
“Exicision of
cancer
head and neck ”
Gold standard
procedure :
“Radical Neck
dissection”

10. In 1951
paper
“Neck
Dissection”
“Routine prophylactic RND
was impracticle”

11.  Martin et al, 1951 – RND shouldinvolve
removingtheSCM, Omohyoidmuscle,IJV,
Submandibularsalivary gland en bloc.. Spinal
accessorynervehastobesacrificedevenif it
causessignificantestheticandfunctional
morbidity.
 Martin has stated “ Any technique that is
designed to preserve the spinal accessory
nerve should be condemned”

12.  Conley alsosupportedtheconceptofradicalneck
dissection.
 Suarez (Father of Functional neck
dissection), 1952 – developedFunctionalNeck
dissectiontopreventsignificantlongtermmorbidity
of RND:
1. shoulder dysfunction,
2. cosmetic deformity,
3. cutaneous paresthesia,
4. Chronicneckandshoulderpain syndrome..

13.  Peter antony, 1953 – Astrongproponentof
bilateralelectiveneckdissectionrecommended
sparingthespinalaccessorynerveandatleast
oneInternaljugularvein.
 Bocca,1967 – Functionalneck dissectionisa
completedissectionof thelateral cervicalspace,
anatomicallyconfinedbyafascial envelopeand
itself containingthemajorcervical lymphatics.

14. 

Bocca & Gavlin- popularizedtheFunctional
neckdissection.
Medina, 1989 – Lymphadenectomiesshouldbe
categorizedasComprehensive,Selectiveor
Extended.
 Robbins et al, 1991 – usedtheterm‘Selective’
todistinguishthepatientswhohadoneormore
groupoflymphnodespreserved.

15.  PLATYSMA MUSCLE:
◦ Wide, quadrangularsheetlike
muscle
◦ Extendsobliquelyfromupper
chesttolowerface,hence
doesnotcoveravariable
inferiorlybasedtriangleinthe
anterioraspectof theneck&
posterolaterally.
◦ Locatedimmediatelydeepto
thesubcutaneoustissue.
◦ TIP: SPARK OF CAUTERY
SHOULD BE BELOW THE
PLATYSMATO BE SURE
YOU’RE INTHE CORRECT
PLANE.

16.  MARGINALMANDIBULAR NERVE:
◦ Suppliesmusclesof lowerlip,henceneeds preservation.
◦ InDingmanandGrabb'sclassicdissectionof 100facial
halvesin1962,themarginalmandibularbranchwasas
muchas1cmbelowtheinferiorborderin19%of cases.
Anteriortothepointwherethenervecrossedthefacial
artery,alldissectionsdisplayedthenerveabovethe
inferiorborderof themandible.
◦ Identifynerve1cminfrontandbelowtheangleof
mandible- incisesuperficiallayerof thedeepcervical
fasciathatenvelopstheSubmandibularglandparallelto
nerve direction

17.  Anotherimportant
findinginthestudyby
DingmanandGrabb
wasthatonly21%of
caseshadasingle
marginalmandibular
branch;67%hadtwo
branches,9%had
threebranches,and
3%had four.

18.  Relevant neck
trianglesduring
Neckdissection:
1. Anteriortriangle
2. Posterior triangle

19.  Boundedby:
 Anteriorly-Median plane
 Posteriorly-
Sternomastoid
 Superiorly- Inferior
borderof mandible
 Inferiorly-Manubrium
sterni

20.  SUBMANDIBULAR
TRIANGLE:
◦ Boundedbelowbytwo
belliesof Digastricmuscle&
abovebylowerborderof
mandible..
◦ Floorisformedby
Mylohyoidmuscle
◦ Roof of triangleformedby
skin&platysma.
◦ Containssubmandibular
salivaryglandwhichis
resectedbecauseof its
associatedlymph nodes.

21.  Othercontentsofthetriangle:
◦ Marginalmandibular nerve
◦ Facialvein&arterysectionedneartheangle.
◦ Veinstayssuperficialtogland&runsdownward&
backwarddeeptoplatysma.
◦ FacialarteryarisesfromECA &passesupwardstowards
mandible.Itapproachesthetriangledeeptothegland
andloopsaroundittoemergeatthelowerborder
alongsidethe vein.

22. FACIAL ARTERY

23. Anteriorly– Sternocleidomastoid
muscle
Posteriorly– Trapezius muscle
Base– Middlethirdof theclavicle
Apex– Intersectionof SCM & Trapezius
nius
ssue,
Floor – Scalene, levator scapulae, sple
capitis.
Roof – Overlyingskin,subcutaneousti
platysmaanteriorly
Contents:Fibrofatty tissue & lymph nodes

24. 

Atapex,floor&roofareclosetoeachother&at
base,floorpassestofirstrib&roofattachesto
clavicle..
Whileclearingthefibrofattytissueatthebase,
caretobetakentoavoidpullingtheSubclavian
veinalongwiththeloosemobilefat.


Structuresofsurgicalsignificancelieinthelower
part.
AtanglebetweenSCM &Clavicle,EJVpasses
intoSubclavianvein.

25.  SPINALACCESSORY NERVE:
◦ Itsextracranialcoursehasthree parts:
1. Belowjugularforamenexternalbranchof thespinal
accessorynerveislocatedmedialtothedigastric&
stylohyoidmuscles&lateraltoIJVincloseproximity
toupperdeepjugular nodes
2. Nextitpassesintothesubstanceof theSCM &
emergesjustabovemiddleof the muscle
3. Thereafteritrunsposterioranddownwardsthrough
posteriortriangletoenterdeeptotrapeziusapprox.2
cmaboveclavicle.

26.  Twopeculiarcharacteristicsofthethirdpartof
surgicalsignificance :-
1. NervedoesnotenterTrapeziusmusclebut
coursesalongthedeepsurfaceof themusclein
closerelationshipwithtransversecervical
vessels.
2. Locatedrathersuperficialmiddleposterior
triangleof neckandcanbeeasilyinjuredwhile
raisingposteriorskin flaps

27.  CN XI– RelationshipwiththeIJV

28.  LYMPHNODES &LYMPHATICS:
◦ Cervicallymphaticsystemisdividedintosuperficial&
deep chains
◦ Superficialdrainsintodeepafterpiercingsuperficiallayer
of deepcervical fascia
◦ Superficialchainislesssignificantthandeepfrom
surgicalview point.
◦ DeepcervicallymphaticsaccompanytheIJVorits
branchesorliewithinmajorsalivaryglands.

29.  Superior, middle&inferiorgroupsof theanterior
groupof Deepcervicallymphaticsliealongthe
wallof IJVuptoitsentryintosubclavian vein.
 Thusanteriorgroupliesbetweenposteriorbellyof
digastric&clavicle.
 SubdigastricorsuperiorJugularnodesaremost
frequentlyinvolved amongtheanteriorgroupof
deepcervicallymphatics.Alsocalledjunctional
nodesof Fisch.

30.  Subdigastricnodesaremostdifficulttocleardue
totheirproximitytosuperoanteriorpartof
Accessory nerve.
 Lymphnodesof theLateralneckaredesignated
asupper,middleandinferiorcervicalnodes– also
designatedasspinalaccessorygroupof nodes.
 Theybeginbeneathupperpartof SCM &extends
downward&backwardfollowingcourseof Spinal
Accessory nerve

31.  Fromsurgicalviewpoint,spinalaccessorygroup
receivesdrainagefromnasopharynxbut it
communicateswithsubdigastricnodes.
 Inferiorly,itturnsforwardinto supraclavicular
groupof lymphnodestojointhedeepcervical
nodesorInternaljugularchainof lymph nodes.

32.  Insubmandibulararea,therearethreegroupsof
lymph nodes:
1. Preglandular
2. Interglandular
3. Prevascular&Retrovascular..
 Theydrainthemucosaoflowerlip,cheeks,
alveolarregion,floorofmouth,anteriortongue&
thenemptyintodeep chain.

34.  IA (submental) Lymph
nodeswithinthetriangular
boundaryoftheanterior
bellyofthedigastric
musclesandthehyoidbone
 IB (submandibular)
Lymphnodeswithinthe
boundariesof theanterior
bellyof thedigastricmuscle
andthestylohyoidmuscle
andtheinferiorborderof
themandible

35.  IIA and IIB ( upper jugular)
Lymphnodeslocatedaround
theupperthirdoftheinternal
jugularveinandtheadjacent
spinalaccessory nerve;
 Level IIA lymphnodesare
locatedanterior(medial)tothe
spinalaccessory nerve;
 Level IIB lymph nodes are
located posterior (lateral) to
thespinalaccessorynerve

36. III ( middle jugular) Lymphnodes
locatedaroundthemiddlethirdof
theinternaljugularvein;nodesare
locatedbetweentheinferiorborder
of thehyoidboneandtheinferior
borderof thecricoidcartilage
 IV ( lower jugular) Lymphnodes
locatedaroundthelowerthirdof
theinternaljugularvein;nodes
extendfromtheinferiorborderof
thecricoidcartilagetothe clavicle

37. 


V ( posterior triangle) Lymph
nodeslocatedalongthelowerhalf
of thespinalaccessorynerveand
thetransversecervicalartery;
supraclavicularnodesarelocated
inthisgroupof lymph nodes
Level VA - alongthelowerhalf
of thespinalaccessory
Level VB - transversecervical
artery

38.  VI (central
compartment) Lymph
nodesintheprelaryngeal,
pretracheal,andboundaries
arethehyoidbonetothe
suprasternalnotchand
betweenthemedialborders
of thecarotidsheaths;
lymphnodesaregenerally
notdissectedinoralcancer
patients

39.  VII (superior mediastinal) Lymphnodesinthe
anteriorsuperiormediastinumand
tracheoesophagealgrooves,extendingfromthe
suprasternalnotchtotheinnominateartery;lymph
nodesaregenerallynotdissectedinoralcancer
patients

41.  Clinicalpalpation
 Ultrasonography
 Fineneedleaspirationcytology (FNAC)
 USG guided FNAC
 Computedtomogramscan(CT Scan)
 Magneticresonanceimaging(MRI)
 PET scan
 Intraoperativesentinelnodebiopsy
 Intraoperativefrozensection

42. 

Clinical palpation assesses criteria like site,
number, size, shape, consistency &fixity of the
necknodes.
Notuniformlyreliableintheassessmentof
regionalmetastaticdiseaseasoccultneck
diseasecanoccurinupto50%ofpatients,false
negativeraterangesbetween0%and 77%.


43.  Ultrasonography issuperiortoclinical palpation
forassessmentof cervicalnodes
 Ultrasoundcriteriaformalignantandbenign
nodes- size, shape, central necrosis,
extracapsular spread, roundness index &
status of hilum

44.  Size:
◦ Maximumtransversediameter
◦ Assessestrueaxial&transverse diameter
◦ 33%- 71%nodes< 1cmfoundtohave metastases
◦ optimalminimalaxialdiametertodistinguishbetween
positiveandnegativenodeprovedtobe8mmfor
subdigastriclymphnodeand7mmforallothertypesof
lymph nodes

45.  Shape:
 Benignlymphnodeshave
anelongatedfusiform shape
 Malignantinfiltration
commonlybeginsincortex
of thelymphnode.
 metastaticlymphnodes
tendtohaveanirregular
roundedshapethatis
reflectedbythedecreased
ratiobetweenthe
longitudinalandtransverse
(L/S) diametersofnode

46. Round node
Oval node

47.  Extra Capsular Spread:
◦ Normallymphnodehassmooth, well-delineated
margins.
◦ Metastatic node becomes ovoid; margins of the node
may remain smooth until the advanced stages of the
diseasewhenextracapsularextension occurs.

48.  Hilum Of The Lymph Node:
Normallythehilumofthelymph nodeiscentrallylocatedandthick.
Itisformedbytheparallel arrangementofthecentral lymphatic
sinusesandisa reflectionofthenormalnodular architecture.
Malignantinvasionofthecortical parenchymaofthenodemakesthe
hilumeccentric,thinned.

49.  Fine Needle Aspiration Cytology (FNAC)
Techniqueisusefulfordiagnosisof deeplysituated
masses
Confirmationof tumorinsuspiciouslyenlargedneck
nodes,
Assessmentof areasof possiblerecurrent diseases.
Reliableand inexpensive
Toleratedby patients.

50. Aneedleispassedintothe
targetmassandcellsare
aspirated.Thesuccessof this
methoddependsonthe
accuracyof needleplacement
andthereliabilityof the
diagnosis,ontheskilland
experienceof thepathologist.
Whenitiscombinedwith
ultrasonographyitisahighly
accuratetechniqueforthe
investigationof cervicallymph
node metastasis.

51.  CT Scan
◦ Helpfulforevaluation of
theprimarytumouras
wellasforevaluationof
thenecknodesfor
metastases,

52.  Tellsaboutsize, shape
(ovalorspheroid)andalso
whethertheywere
homogenousor cystic.
 ThemostaccurateCT
criteriaisthepresenceof
centralnecrosiswhichis
demonstratedas
peripheral/rim enhancement

54.  Sentinel Node Biopsy (SNB)
◦ Importantroleof sentinelnodebiopsy(SNB) clinicallyN0
neckinpatientswithoralsquamouscellcarcinoma.
◦ Itisconcludedoverallsensitivityof theprocedureusing
thefullpathologicprotocolwas94%&sentinelnode
biopsycouldbeusedtostagetheN0neckinpatients
withearlysubclinicalnodaldisease.

55.  Rationale:
◦ Cervicalmetastasisisthesinglemostimportant
prognosticfactorinpatientswithoralcancer,withthe
presenceof nodalspreaddecreasingthe5-yeardisease-
freesurvivalratebyapproximately 50%.
◦ Improvingtheaccuracyof stagingwhilereducingthe
morbiditycausedbyunnecessarylymphadenectomyin
carcinomasisuseful

56.  Sentinelnodemappinguses:
 (1) radioisotopescanimaging;(2) injectionof blue
 dye;and(3) useof ahandheldisotopetracerprobefor
localization.
 Ithasbeenshownthatthecombinationof allthreetechniques
increasestheaccuracyandtheyieldof sentinellymphnode
identification.Apreoperativetechnetiumscanisobtainedfirst,
whichrequiresinjectionof aradioactivetechnetium99m–labeled
sulfurcolloid.Ingeneral,0.05mCiof theisotopeisinjectedin
fourquadrantsaroundtheprimarylesion,andagammacamera
isusedtoobtainvisualimagesat3minutesand15minutesand a
delayedimageat1hour.

57.  Usuallythefirstlymphnodeidentifiedbythetechnetium
scanisconsideredthesentinellymphnode.Insome
patientsmorethanonesentinellymphnodeis identified.
 Immediatelypriortothesurgicalprocedure,isosulfan
bluedye1%(Lymphazurin)isinjectedsimilarlyinfour
quadrantsaroundtheprimarytumor.Nomorethan0.5
mLof thedyeisinjectedinthesubdermalplanearound
thetumor.Theoperativeproceduretheniscarriedout
within30minutesof theinjection.

58.  RobbinswhochairedTheCommitteeforHead &
NeckSurgeryandOncologyof theAmerican
Academyof Otolaryngology– HeadandNeck
Surgery,alongwithcolleaguesdeveloped
standardizedneckdissectionterminologyin1991
andupdatedtheclassificationin2002.

59.  Originalclassificationwasbasedonthefollowing
concepts:
(1) TheRND isthefundamentalprocedurewithwhich
allotherneckdissectionsare compared,
(2) MRND denotespreservationof oneormore
nonlymphatic structures,
(3) Selectiveneckdissectionsdenotepreservationof
oneormoregroupsof lymph nodes,
(4) ExtendedRND denotesremovalof oneormore
additionallymphaticornonlymphatic structures.

60. 1. RadicalNeck Dissection
2. ModifiedRadicalNeckDissection
3. SelectiveNeck Dissection
a. SupraOmohyoidneckdissection(I, II,III)
b. Lateralneckdissection(II, III,IV)
c. PosteroLateralneckdissection( II,III,IV, V)
d. Anterior
4. Extendedneckdissection

61. 1. RadicalNeck Dissection
2. ModifiedRadicalNeckDissection
3. SelectiveNeck Dissection
◦ Eachvariationisdepictedby‘‘SND’’ andtheuseof
parentheses todenotethelevelsorsublevels
removed
1. Extendedneckdissection

62. Modifiedradicalneckdissection(MRND)
wasfurtherclassified



MRND I – Preservesspinal
accessorynerve.
MRND II – Spinalaccessory and
sternocleidomastoidmusclebut
sacrificesinternaljugularvein.
MRND III – Requirespreservation of
SAN, sternocleidomastoidmuscleand
internaljugular vein

64.  T – Tumor size
◦ Tx– tumorcantbeassessed
◦ T0 - noevidenceof primary tumor
◦ Tis– tumorinsitu
◦ T1– tumorsizelesthan2cm
◦ T2– tumorsizebetween2– 4cm
◦ T3– tumorsizemorethan4 cm

65. T4a(lip) – tumorinvadesadjoiningbone,IAN,floorof
mouth,orskinof face,i.e., chinornose
T4a(Oral cavity)– tumorinvadesadjoiningstructures
likebone,deep[extrinsic]muscleof tongue
[genioglossus,hyoglossus,palatoglossus,and
styloglossus],maxillarysinus,andskinofface)
T4b(Oral cavity)– tumorinvadesmasticatorspace,
pterygoidplates,orskullbaseand/orencasesinternal
carotid artery

66.  Regional lymph nodes (N)
◦ Nx– Regionallymphnodescannotbe assessed
◦ N0 - Noregionallymphnodemetastasis
◦ N1– Metastasisinsingleipsilateralnode,lessthan3cm
ingreatest dimension.

67. N2A- Metastasisinsingleipsilateralnode,morethan
3cm&lessthan6cmingreatestdimension
N2B- Metastasisinmultipleipsilateralnodes,nonemore
than6cmingreatestdimension
N2C- Metastasisinbilateralorcontralateralnodes,none
morethan6cmingreatest dimension
N3– Metastasisinlymphnodemorethan6cmin
greatestdimension.

69.  Distant metastasis (M)
◦ MX:Distantmetastasiscannotbeassessed
◦ M0:Nodistant metastasis
◦ M1:Distant metastasis

70.  Philosophyofmanagementofmetastaticdisease
inthecervicallymphnodeshaschangedoverlast
fewdecadeswithabetterunderstandingofnodal
metastasis,subclassificationofL.N. &SND.
RND is largely replaced by
SND

71. ◦ Age&generalconditionofpatient
◦ Siteandsizeof primary
◦ Palpableneck nodes
◦ Extentof diseaseonimaging
◦ Asimpleguidelinefollowedistogo1stepbelowthe
node.

73.  Toavoidcomplicationssuchaswound
breakdown,skinflapnecrosis,exposureofcarotid
arteryfollowingneckdissection,selectionof
correctincisionisnecessary.
 Studyonanatomyof bloodsupplyof skinflapsof
neckconductedbyFreeland&Rogers,1975–
gaverisetoincisionslikeApronincision,which
aremostlikelytosafeguardbloodsupplyofskin
flaps.

74. 1. Providefreeaccesstotheoperativesite
2. Shouldnotlieonvitalstructuresof theneck
3. Shouldbedesignedinsuchaswaythatblood
supplyof theneckskinflapsisnotcompromised
– toavoidskinflapnecrosis,wounddehiscence,
exposureof vitalstructuresof neckeg.Carotid
artery.

75.  Incisionsareofthreemaintypes:(McGregor)
1. Hayes– Martin incision
2. Tri-radiateincisionoritsmodification
3. McFee incision

76. Transverse incision
Have cosmetic advantage as
they follow natural skin
folds of the skin
Recovery of scar tissue
in these folds are rapid
and successful
Vertical incision
Not preferred because they
intersect the natural skin
folds and the vascular
supply of the neck
They tend to contract along
their long axis – leads to
deformity and restricted
action.
Easy to modify

77. 1. ‘Y’ incisionof Crile (1906)
2. Double‘Y’ incisionof Martinetal(1951)
3. Schobingerincision (1957)
4. Superiorlybased‘Apronlike’incisionof Latyshevesky&
Freund (1960)
5. Mcfeeincision(1960)
6. Conleyincision (1970)
7. ModifiedConleyincisionbyLasaridisetal(1994)

78.  Advantages
good◦ Incision provides
exposuretosurgicalsite.
 Disadvantages
◦ Flap necrosis is high due to
disruption of vasculature of skin
flaps
◦ Occurrence of flap separation
atthetrifurcationsite.

79.  Schobinger(1957)
 Cramer&Culf (1969)
 Conley (1970)

81.  Itisapaired‘Y’ incision.
 Here the submandibular
component is met by a
verticallimbwhichbelow
becomescontinuous with
an inverted ‘Y’ in the
suprascapularregion.
 Thisflapmostoftengets
cyanosed.
 Flapnecrosisandcarotid
exposure is more in this
typeof incision.

83. 
curving vertical
Suggested a posteriorly
incision

rather than a horizontal
incision
Theincisionstartsfromthe
regio
n by
and
running
submental
ending
downwards
anterior border
along the
of the
level
of
curvin
g
trapezius to
the
clavicle gently
posteriorly.

86.  It avoids
limb.
 Two
a vertical
horizontal
incisions are used
one in submandibular
region and other in
the suprascapular
region.

87. Advantages Disadvantages
Excellent cosmetic result (McFee 1960,
McNeil 1978)
There is no lessening of vascularity
in the centre of the flap (Ariyan
1986)
There is no angle intersection in
incision (McFee 1960)
Post operative wound recovery is rapid
(McFee)
Suitable in necks receiving radiotherapy
and in peripheral vascular disease
(Maran et al 1989)
Recovery of flap excellent due to
wide bipedicled flaps (Stella & Brown
1970, Daniel & McFee 1987)
Exposure is not good (Hetter 1972)
It is not suitable for bilateral
simultaneous neck dissection (Chandler
and Ponzoli 1969)
Operating period is long (McFee 1960)
Posterior triangle dissection is difficult
(Maran et al 1989, White et al 1993)
Difficulty may arise while working
under the bridge flap
In short neck it might be difficult to
distinguish between the front tip of
the incision from that of the
tracheostomy.

88.  Described by Latyschevsky and
Freund 1960.
 Only a horizontal incision from
mastoid to mastoid gently
curving inferiorly upto upper
border of the thyroid cartilage is
used.
 Advantages
◦ Carotidarteryiswellprotected
 Disadvantages
◦ Venous congestion and
oedema mightdevelopat
thebottom corner

89.  Lowerendof IJV
 Junctionof Lateralborder
of claviclewiththelower
edgeof trapezius
 Submandibulartraingle
 Upperendof IJV

90. PHILOSOPHY OF STELL AND MARAN:
AGGRESSIVE FIRST, CONSERVATIVE LATER

91. 1. McGregor– Cancerof theheadand neck
2. J.P. Shah
3. Farquharson’s operative sx
4. SRB manual of surgery
5. Slideshare inputs from oncosurgeon
from sloan kattering cancer centre
NY,usa

92. Thanks for your valuable comments
carry home images are as follows

95. HAPPINESS IS NOT
THE DESTINATION ;
IT’S THE WAY WE
COVER THE PATH.